The Perfect Predator

by Steffanie Strathdee

  Slow improvements showed up in his labs and charts even when they weren’t visible to us. And then sometimes in unexpected moments, he would say or do something and suddenly seemed to be firing on all cylinders again. I was lying in bed one morning at the hotel when the phone rang. As I reached it for it, I thought, they’re either calling to me he’s dead, or—

  “Hi, honey!” It was Tom.

  “Wow, you’re up—how are you feeling?

  “Better,” Tom said. “Why aren’t you here?”

  “Um, because it’s five thirty in the morning?”

  “Well, when you come, can you bring a croissant and juice and a pear and some Coke with you?”

  “Sure, but I don’t think you’re supposed to have Coke—”

  “Just bring it, dammit,” Tom begged. “I’ll just have a little sip.”

  And just like that, he took a giant step back from death’s door, like it had all been just a bad dream.

  At the hotel breakfast buffet, I tucked Tom’s breakfast requests into my bag, downed a quick bowl of muesli and yogurt, and grabbed my coffee to go for the brisk walk to the Uniklinik. He was gleeful and devoured everything I brought him within minutes, barely stopping to talk. I texted the girls so they could go shopping to get him more.

  “Fank oo,” he said, giving me a little wave, as he talked with his mouth full.

  “Did you say ‘fuck you’ or ‘thank you’?” I asked with a smirk. A half an hour later, neither of us was laughing. Tom was glassy-eyed and in a stupor. His pallor had whitened under a sheen of perspiration.

  “Are you okay?” I asked him, hardly believing my own eyes. Suddenly, the look on his face resembled the look Cameron gave me when he was a baby, right before he threw up his bowl of SpaghettiOs all over my nightie. “Oh God, where’s a bucket!?”

  No bucket would have been big enough. Tom threw up projectile vomit halfway across the room. It was black and viscous matter like nothing I’d ever seen. And it was everywhere. I rang the call button over and over, but no one was coming. “Help!” I cried down the hall. His nurse, Birgit, came running. Her eyes widened as she took in the scene while grabbing her gloves and flinging the protective gown over her head. It took Birgit and an aide over thirty minutes to clean up the mess. Tom watched, dazed, but his color looked much better.

  I tried to shake off the morning’s crisis with a bit of humor. “Just think, honey,” I told him. “If your head had rotated around a few times, you would have been perfectly cast for a remake of The Exorcist.” Tom looked at me, but did not crack a smile. Lights on; no one home.

  Once the room was cleaned up and Tom’s hospital gown changed, Birgit and I spent some time trying to clean black vomit from Tom’s goatee. It was slow going, and he started to whine.

  “How about we shave it off?” I suggested. “I’ve never seen you without a beard. It might even be fun.” Tom shrugged. Birgit was happy to comply, and within twenty minutes, Tom was barefaced. He’d always been kind of movie-star handsome, his shock of silver hair and a goatee giving him the dashing look of a forever-fifty-something. I barely recognized the man in front of me. He looked like his father. What had I done?

  In retrospect, the Exorcist scene and barbering mishap were just a warmup for worse things to come.

  Later that morning, Dr. Zeuzem knocked gently on the door and entered. He was gloved and gowned but this time also wore a face mask, so only his eyes showed, showing less of his face than the hijabs the nurses wore in Luxor.

  “I regret to tell you that our microbiology lab has now cultured the sample from the pseudocyst that was collected during the procedure the other day,” Dr. Zeuzem told us. “The pseudocyst is infected with the worst bacteria on the planet. Acinetobacter baumannii. This microbe has been responsible for the closure of several ICUs across Europe in recent months. It is the worst news we could have had.”

  “Acineto what?” I asked, interrupting him. My degree in microbiology was rusty. I was drawing a blank.

  “Acinetobacter baumannii,” Dr. Zeuzem repeated, pronouncing it more slowly: ass-eh-NI-to-bacter bow-MAHNI. He wrote the genus and species down for me on the back side of the printout of daily lab values. As soon as I saw the words written down, they rang a bell. I remembered plating this organism on Petri dishes back in my microbiology class in the 1980s. But it required no special handling at the time. Strange.

  The rise of A. baumannii as a drug-resistant strain had followed a similar path to that of others, like MRSA, that were showing up more and more in the news. Some years ago, A. baumannii was just another of the billions of ubiquitous bacteria that coexist with humans in our guts, on our skin, and in soil and water. It generally threatened only people whose immune systems were severely compromised, and even then, it was sensitive to antibiotics and thus treatable. Then it became a resident in hospital settings, where vulnerable populations, indiscriminate use of antibiotics, and poor infection control measures provided the ideal breeding ground for multi-drug resistance.

  President Obama had prioritized the ESKAPE pathogens, the seven most dangerous superbugs, for research funding in an executive order; each letter in ESKAPE represented a different bacteria that had acquired multidrug resistance. S was for MRSA, the Staph superbug we had acquired in Goa. A. baumannii, the A in that lineup, was the one taking Tom down now. A few months later, it would achieve the number one ranking on the World Health Organization’s list of the world’s twelve most deadly superbugs. The dirty dozen.

  Dr. Zeuzem continued. “The lab is running the antibiotic sensitivity analysis, which will take another day or two, but I have asked them to do so urgently. I must tell you that this is an ESKAPE pathogen that is renowned for antibiotic resistance. Given that you were in Egypt, it is likely that you acquired this pathogen there, which is worrisome. Egyptian strains tend to be highly resistant.”

  “The cyst also contains a fungus, Candida glabrata, which is not unexpected. While we wait for the sensitivity results we already placed him on our best-guess combination of antibiotics, and we will initiate a fungicide.”

  Within minutes of Dr. Zeuzem’s departure, Tom was fast asleep. Given his delirium, I didn’t think his brain had registered the fear that filled the room, but mine had. His pancreatitis, as bad as that was, had been eclipsed now by the presence of this massive pseudocyst teeming with a type of bacteria that was, more often than not, highly antibiotic-resistant. I’d read in a general way about the rise in multi-drug-resistant bacteria, but mostly as a concern limited to specialized hospital settings or nursing homes where there were numerous high-risk patients with weakened immune systems. That wasn’t Tom. Or at least it hadn’t been Tom before now. Nobody could know where and how he picked up the pathogen, but the pseudocyst in his abdomen gave it a place to settle in and fester.

  While Tom slept, I googled Acinetobacter baumannii and boned up on its epidemiology and pathology. Our pal A. baumannii had been discovered in the soil about one hundred years ago by the Dutch microbiologist and botanist M. W. Beijerinck, now considered one of the founders of microbiology and environmental microbiology.

  If it weren’t for the fact that it was in the process of trying to kill my husband, I’d have to admire the microbe and its superpowers. This bacterial kleptomaniac collected genes from other bacteria that arm it for resistance to antibiotics. Trading these little disks of DNA, or plasmids, like my son, Cameron, had once traded Pokémon cards, it shuffles, deletes, or reorganizes them to craftily evade the host’s immune system. Its other nifty biological tricks include growing a slimy capsule that inhibits the immune response. And it creates biofilms, which are complex Borg-like microbial communities that enable the bacteria to survive in extreme conditions—the ultimate evolutionary advantage. A. baumannii thrives on all kinds of surfaces, like countertops and door handles, linens, and the hard-to-reach insides of medical devices. They can even stick to body lice.

  A. baumannii is nicknamed Iraqibacter, because more than three thousand wounded American
and European soldiers and military contractors were diagnosed with it upon their return from fighting in the Middle East between 2003, when the bacteria was first identified, and 2009, the last time the Department of Defense made statistics public. Those were conservative estimates, limited to just those patients tested for the bacteria. At various points during that period, as many as 20 percent of wounded soldiers in military hospitals carried it. Its early links to Iraq fed rumors that Iraqi insurgents had placed A. baumannii–laced dog feces and rotting meat in incendiary devices, so that the shrapnel would not only wound but also contaminate its victims. But it was lax infection control procedures in the US military that were believed to have accelerated its transmission, which unwittingly spread it between hospitals in the Middle East, Europe, and the US. In fact, to propagate itself A. baumannii proved adept at manipulating not only the microbial world but an entire healthcare system.

  This ticked me off, from both a global health perspective and a personal one. While A. baumannii went its way undetected or unreported, my husband was about to become some nameless statistic in the CDC’s Morbidity and Mortality Weekly Report. I stopped reading, hoping that Tom would luck out and not harbor one of the multi-drug-resistant strains Dr. Zeuzem was worried about.

  Luck was not on our side. Late the next day, I asked a nurse for a copy of the antibiotic sensitivity results that had just come back on Tom’s bacterial isolate. Although the report was in German, I got the gist. Of a list of fifteen antibiotics, all but three were marked R, which meant that Tom’s isolate was resistant to them. That left only three antibiotics to which it was partially but not fully sensitive: meropenem, tigecycline, and colistin. Colistin is a “last-resort antibiotic” because the side effects can be gruesome. Developed in World War II, it’s not exactly a modern miracle drug. I had never heard of the other two. A quick Google search indicated that these were the big guns in the antibiotic world, real gorilla-cillins.

  I typed the terms pancreatic pseudocyst and Acinetobacter baumannii into PubMed. Might as well cast the widest possible net for any relevant leads to treatments. Up popped a single paper. It described a case report of a patient who had been successfully treated with surgery to remove the pseudocyst, as opposed to abdominal drains to siphon off infected fluid. I downloaded a PDF of the article and emailed it to Chip. It was hard to predict what he’d make of it, but his natural instincts as both a clinical purist and pragmatist meant he considered everything for its potential.

  Within the hour, a new IV line was started to pump Tom full of these three antibiotics, and the nurse changed the instructions on the outside of Tom’s door. Infection control procedures were now even more strictly enforced. In addition to gloves and a gown, everyone was required to wear face masks and disinfect twice before and after leaving his room.

  I needed to find out what this meant for Tom’s prognosis. I removed my gloves, gown, and face mask, washed my hands twice vigorously, and proceeded to walk deeper into the ICU toward the nurses’ station, where the doctors tended to aggregate. As I approached, I recognized one of the doctors who was part of Tom’s care team. She was seated and reviewing paperwork with a pencil tucked over her ear, but when she saw me coming, her face became flushed and a scarlet blotch crept up her neck, like an amoeba.

  “What are you doing down here?!” she shouted at me.

  Dumbfounded, I tried to explain that I had a few questions about Tom’s infection, and added that I had diligently disinfected according to the new infection control procedures.

  “Didn’t Dr. Zeuzem explain to you that this is the worst bacteria on the planet?” Her shrill voice escalated to a fever pitch. “Please, don’t come any closer. Just—just turn around and go back. We have many, many sick patients in this ward who are getting transplants or chemotherapy. If these bacteria spread, it will kill them all!”

  A. baumannii was shaping up as a devious foe. It had hidden inside the pseudocyst and, by doing so, cloaked itself there behind the pancreatitis we’d thought was the big threat. All the while, the Iraqibacter was multiplying and taking over as we killed off all the friendly bacteria—bacteria that help us stay healthy—with the other antibiotics. We’d been played. We’d set things up perfectly for a hostile takeover. If we had any chance of outsmarting this superbug, we’d have to adapt ourselves and our medical arsenal, strategy, and tactics for this new fight.

  Tom: Interlude II

  The wind is howling around me in the hazy murk. Swirling around me are torn bits of paper, dead leaves, and dirt. The skin on my face is blown taut against my skull; my mouth is open in a scream no one can hear. I can’t even close my eyes. I am being forced to watch what is happening around me, the remnants of my life.

  I am holding on to a pole with all my might. The gale is so strong it envelops me, whipping at my thin hospital gown and lifting me up, so I am horizontal. If I let go, I will die. I hear faraway voices that are familiar. One is my mother, telling me not to let go. She is calling out to me, but the wind carries her voice away. I want her to hold me and take away the pain. I pull myself close and hug the pole instead.

  The pole suddenly swings ninety degrees under me and I am looking down, where I see flames. My entire being is made up of pain that can no longer be contained inside my body; I am a ball of hot, white light. I am on a spit, spinning on a rotisserie. Skewered. As I spin, lightning bolts of white light drip off me into the flames below, making them glow brighter. I am looking into hell.

  To live or die, my decision. Hold tight or let go? I am so tired. Must I decide? There are more voices now. Steff. The girls. Others. We are here. I love you, honey. Please don’t go, Pappy. Just hang on. We’re going home.

  Yes. I want to go home.

  PART II

  Can’t ESKAPE

  Gentlemen, it is the microbes who will have the last word.

  —Attributed to Louis Pasteur

  9

  HOMECOMING

  University of California–San Diego

  Thornton Hospital, La Jolla

  December 12–13, 2015

  Home sweet home. Sort of.

  Chip pointed out that it helped to be at a medical center experienced with Iraqibacter. Back in San Diego, with military bases and VA connections, they had that in spades.

  “Over here, we have more Iraqibacter than you can shake a stick at,” Chip had said. “So let’s get him home.”

  Although the flight home from Frankfurt to San Diego was much longer than the one from Egypt to Germany, the Lear jet air ambulance was even smaller than the one before. It didn’t even have a lavatory and had just enough room for Tom, four medevac personnel, and the pilot. No room for me. The choice of this super-compact plane had to do with infection control concerns that had almost scuttled the evacuation entirely. Luckily, Chip was able to reassure the travel insurance company that regular contact precautions were all that were needed, so the arrangements could proceed. I flew back to San Diego on a commercial flight. It was gut-wrenching to leave Tom at the hospital, not knowing whether I would ever see him alive again, but in one of his more lucid moments, he urged me to go on ahead so I could meet him at the UCSD hospital upon his arrival.

  I arrived home in Carlsbad in the early evening, and unlocked the door to greet our cat, Sir Isaac Newton. The black M that arched between his eyes—a signature of the Maine coon—furrowed as he eyed me reproachfully. I had been gone nearly three weeks, and for the last week he had been taken care of by a house sitter after I had finally persuaded my parents to fly home. They’d already stayed much longer than planned. I popped a few melatonin and collapsed into bed. Newton continued pacing the house, moaning. No, boy, Daddy isn’t coming home. Not yet. But soon, hopefully.

  Now that we were home, I was confident that, as rotten as Tom felt right now, they’d get him through this and home in time for Christmas.

  UCSD’s Thornton Hospital in La Jolla was only a five-minute drive from my office at the university, but I’d never been there before. A
s I arrived, the morning sunshine and ocean breeze kissed the day with bright promise. The glass doors opened into a lobby that felt more like a Hollywood hotel than a hospital. A doorman in a charcoal double-breasted suit stood by, and the soaring atrium entry bathed the marbled interior in light. A double row of palm trees lined the path to the elevator. Plush chairs were clustered strategically, some for conversation, others for visitors who sat slumped, trying to catch a few Zs.

  I followed the signs to the Thornton Intensive Care Unit—the TICU—on the second floor, and hit the buzzer as the instructions outside the door indicated. The double doors swung open automatically to reveal a beehive of activity. The unit was small, with only twelve beds—private patient rooms lining the rectangular space—most of which faced the nurses’ station. Several nurses and doctors stood behind the long desk of the nurses’ station, heads down, reviewing notes. A few others were talking on the phone. At one end of the hall, a group of doctors and some residents I recognized from our department at the university were huddled around their mobile computer stand, like bees around a flower, conducting rounds. Behind the nurses’ station was a whiteboard with the first name and first initial of each patient’s last name. “Thomas P” was assigned to Bed 8. As I approached Bed 8 with trepidation, I recognized Davey’s familiar voice. He was standing inside the doorway, wearing a yellow gown and blue hospital gloves, conferring with Chip by phone. En route from Mozambique, Chip had stopped in Virginia to visit his daughters before Christmas.

  “Steff!” Davey exclaimed. He quickly discarded gown and gloves, washed up and stepped into the hall for a hug. Davey’s cherubic face, dimples, and bright blue eyes underscored the fact that he had not yet turned forty-five. But he was such an old soul in the way he navigated these fraught straits. I choked back a few tears as I looked past them at Tom who was lying in bed, deathly white. Sleeping or unconscious.